Opinion – Affordable Care Act

Posted on February 6, 2014

Jeffrey Patton, MD, as seen in the Tennessean

One little-known, but well-funded aspect of the Affordable Care Act created a program to determine what medicines, treatments and medical devices work best for patients, known as comparative effectiveness research (CER).

To do this, the health care law created an independent board known as the Patient-Centered Outcomes Research Institute, to determine how $1.1 billion should be used to conduct this research and then communicate the results to physicians and patients. As outlined in the law, CER was intended to determine what works best in medicine, and such recommendations were not to be made on the basis of cost alone.

Comparative effectiveness research is nothing new, but many physicians are concerned with the way the government wants to use this research, and I am one.

Part of PCORI’s budget provides for a new $30 million program that puts government contractors between doctors and patients.

Known as “academic detailing,” it should probably be called “government detailing,” because it is government contractors visiting individual physician offices to share the results of comparative effectiveness research studies and encouraging physicians to change medicines they prescribe based on study results. The government will be making specific recommendations on how physicians can cut costs by using their government-funded research results.

In addition to providing comparative effectiveness results, under this new program government contractors will be working to persuade physicians to comply with recommendations of the U.S. Preventive Services Task Force. Recent USPSTF recommendations for breast and prostate cancer angered certain elements of the patient community and also proved that experts can look at the same evidence and come to completely different conclusions.

For example, in 2009 the USPSTF released recommendations that mammography screening for average-risk women under 40 was unnecessary. In doing so, the task force concluded the benefits such as early detection and lives saved did not outweigh the downfalls of screening, which included false-positive results that can lead to further expensive testing.

These recommendations caused an uproar among patients, particularly breast cancer survivors who attribute routine mammogram screenings to saving their lives. In addition to patients, the American Cancer Society rejected the recommendations.

Having this type of one-size-fits-all approach could lead us toward a system like that of the United Kingdom, where CER results are used to impose centralized, national coverage restrictions.

In the U.K., the National Institute for Health and Clinical Excellence uses CER to ration care through coverage decisions, which has resulted in severe consequences for patients. Patients there have faced access barriers to treatments for breast and brain cancer, multiple sclerosis, Alzheimer’s disease, and many other conditions under NICE’s blunt cost-effectiveness standards.

We do not need a NICE system. We need to let physicians make the decisions that are best for their individual patients, not make decisions that are best for government.

Comparative effectiveness research done right is a good thing for our country’s health care system. However, when the government begins telling physicians what medicines they should or should not prescribe, ultimately it’s the patient who suffers. A government-directed academic detailing program based on task force guidelines will ignore individual differences in patients and impose one-size-fits-all recommendations on physicians. There are no safeguards, standards or transparency requirements to protect patients in this program, and we do not want to slide down the slippery slope that puts our health care decisions in the government’s hands.